Drugs to treat/control GI system alterations
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| GI drugs usual desired effects | Decrease secretions. Depress or block CTZ. Alter GI motility to treat: peptic ulcers, vomiting, emetics, diarrhea, constipation.
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| Peptic Ulcers | An ulcer occurring in the esophagus, stomach, or duodenum.
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| Gastric Secretions | HCL- Hydrochloric acid (too much causes ulcers). Pepsin (break down protein).
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| Gastric mucosal barrier (GMB) | Thick, viscous, mucous material that provides a barrier between the mucosal lining and the acidic gastric secretions. No mucosal barrier in esophagus or duodenum.
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| Esophageal Ulcer | Caused by GERD
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| Gastric Ulcer | Caused by break down of the GMB
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| Duodenal ulcer | caused by hypersecretion of acid from the stomach that's passes in the duodenum.
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| Stress ulcer | Thought to be caused by physiological response to stress, release of cortisol which causes increased acid production
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| Predisposing factors in peptic ulcer disease | Helicobacter pylori (H. pylori). Gastroesophageal reflux disease (GERD)
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| Nonpharmacologic Measures to prevent ulcers | Avoid tobacco, avoid alcohol, weight loss, avoid hot, spicy, and greasy foods, Take any NSAIDS including aspirin and oral glucocorticoids with food or in decreased dosage. Sit upright. Do not eat before bedtime. Wear loose-fitting clothing
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| Goal of antiulcer drugs | Decrease causative factors
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| Histamine-2 antagonists (blockers) | Block release of HCL in response to gastrin. Thus reducing amount of HCL secreted.
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| Types of H2 blockers | Cimetidine (Tagamet)- confusion in elderly, last choice due to many adverse effects. Ranitidine (Zantac)**- avoid taking with antacids, use a decrease dose in renal failure**, available OTC in lower dose.
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| Famotidine (Pepcid) | More potent H2 blocker. Prolonged use may mask serious disorders, drugs cross placenta and into breast milk. Adv effects: Diarrhea, constipation, dizziness, headache, confusion, hallucinations, caution with renal disease**
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| Are H2 blockers effective in treating allergies? | No they are not effective in allergies like the H1 blockers studied in resp.**
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| Antacid Functions | Decreases acidity by neutralizing HCL. DOES NOT decrease production of HCL.
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| Available Antacids | Sodium bicarbonate, Calcium carbonate (TUMS), Magnesium salts (Maalox, Mylanta, Milk of mag), Aluminum salts (Riopan, Hydrogel).
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| Side effects of systemic antacids** | Hypernatremia**, water retention, hypercalcemia**, metabolic alkalosis* serum ph > 7.45, May be used to supplement Ca, Na, or to decrease Phos for renal pts
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| How to give antacids for pt unable to excrete Phosphorus | Drug is given WITH meal to bind phos in intestine. (remember increase in phos causes decrease in Ca)**
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| How to give antacids to control gastric pH | Drug is given 1 and 3 hrs after eating**. Must be given 1 hr before or 2hr after other meds.
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| What to watch for with antacids | Ca, Mg, Na. Magnesium containing antacids may be contraindicated if impaired renal function due to risk of hypermagnesmia**. Watch for constipation r/t Ca or diarrhea r/t magnesium content
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| Antacids adverse effects | Metabolic alkalosis, electrolyte imbalance, acid rebound (suddenly stop taking after prolonged use), interfere with absorption of other drugs.
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| Proton Pump Inhibitor actions | Suppress secretion of HCL acid. Prevent hydrogen/potassium adenosine triphosphate (ATPase) enzyme. Inhibit gastric secretion up to 90% greater than H2 blockers**.
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| Proton Pump Inhibitor short term treatment for: | Peptic ulcers, GERD**, H. pylori.
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| Proton Pump Inhibitor Instructions | May cause hepatic impairment**, do not crush**, may open capsules, Pantoprozole and esomeprazole are available in IV form for treatment of acute illness, prevent stress ulcer**
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| Proton Pump inhibitor adverse effects | Dizziness, headache, diarrhea, abd pain, increase in bone loss and decreased Ca levels. Increased incidence of C. difficile diarrhea and pneumonia in long term use.
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| Pepsin Inhibitor/Mucosal Fortifier action | combines with protein to form a cover over the ulcer to protect it from acid and pepsin.
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| Sucralfate (Carafate) | Pepsin inhibitor/mucosal fortifier. 1g 4x day. May bind to other drugs in stomach. Do not give with other drugs**. Tablet-let dissolve in water** usually given as slurry. Do not give with antacids.
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| Prostaglandin analogue | Specifically given to protect gastric mucosal when taking NSAIDS**
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| Pancrealipase | Replacement tx for pancreatic enzyme deficiency. Aids digestion of fats, protein, and CHO, give with meals and snacks. Powder can be irritating to skin, swallow capsule whole.
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| Diarrhea | Defined as frequent loose or liquid stools. Usually not a concern unless more than 1 day or high risk person or extreme amounts
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| Constipation | Defined as hard fecal material in the large intestine. Insufficient water intake and poor dietary habits are contributing factors
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| Causes of constipation | Age- GI motility slows with age. Drug effects, lack of exercise, neurologic disorders,
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| Nonpharmacologic measures to tx constipation | Fluid, activity, bulk fiber**
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| Laxatives use | Result in mild, soft stool
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| Cathartics use | Used to cleanse the bowel**. Result in liquid stool often with cramping***
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| What can determine if the drug is a laxative or a cathartic? | The dose of the drug
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| When laxatives should be avoided** | If there is any question that the client: has an intestinal obstruction, severe abdominal pain, symptoms of appendicitis.
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| Osmotic (Saline) Laxatives | Hyperosmolar laxatives. Pull water into bowel which stimulates stretch resulting in increased peristalsis (water moves from lesser to higher concentration).
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| Types of Osmotic (Saline) laxative | K: Potassium bitartrate, potassium phosphate. MG (Avoid in clients who have renal insufficiency): magnesium hydroxide, magnesium citrate. Na: Sodium phosphate
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| Side effects of Osmotic (saline) laxatives | Electrolyte imbalances, hypotension, weakness. These are powerful!! Be cautious in elderly or ill, increase in urgency may result in falls or rapid dehydration.
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| GoLYTELY | Tends to be a better tolerated osmotic laxative because large fluid shifts do not occur, mechanism is flushing bowel by large volume of fluid which contains some electrolytes. Also available as Miralax powder.
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| Lactulose | Avoid in DM-contains galactose**. Heavy sugar that is poorly absorbed**, creates osmotic pull of fluid into large bowel. Frequently used as gentle laxative or treatment for hepatic encephalopathy (end stage liver disease, rids ammonia from body).
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| Sorbitol** | Osmotic laxative. Sweetening agent (sugarless gum).
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| Stimulants (contact) laxatives | Direct effect on NERVE endings in intestinal mucosa to stimulate peristalsis. Short term use or as bowel prep for diagnostics. Ex. bisacodyl (Ducolax)***
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| Bulk-forming laxatives | Natural fibrous substances that promote large, soft stools by absorbing water into intestine, increasing fecal bulk & peristalsis** Safest and most normal** Must make sure adequate fluid intake! If not they can solidify in intestine & lead to obstruction
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| Stool softeners (surfactant) | Facilitates addition of fat and water in stool. Does not stimulate peristalsis**. Used for prophylaxis to constipation (preventative). docusate (Colace)
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| Lubricant (Mineral oil) | Coats stool, prevents water reabsorption in colon, softens stool, easy passage. Oral may interfere with fat soluble Vitamin absorption**. Caution for aspiration**-oil in lungs.
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| Contraindications for laxatives | Inflammatory disorders of the GI tract: appendicitis, diverticulitis, ulcerative colitis, Chron's. Spastic colon. Bowel obstruction. Pregnancy for castor oil (may stimulate onset of labor).
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| Causes of diarrhea | Foods- high volume, high osmolarity, high fat. Infection- viral or bacteria. Irritants- laxative, blood. Drugs- antiinfectives, prokinetics. Cancer- disruption of epithelial lining or tumor. Chronic disease. Others- surgical removal of part of bowel.
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| Diarrhea can lead to | Nutritional deficiencies r/t malabsorption. Fluid volume imbalances--esp in kids/elderly. Electrolyte imbalances--esp K, Mg***
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| Traveler's diarrhea (acute diarrhea) | Frequent cause: e. coli. Treat with fluoroquinolone antibiotics (Cipro). Preventative measures if water source questionable: don't drink water from a fountain, drink bottled water, eat only cooked vegetables, wash hands**.
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| Rifaximn (Xifaxan) | Antibiotic for traveler's diarrhea. Acts locally in GI tract, very little absorbed. Do not use if bloody diarrhea. Do not use if diarrhea > 48 hrs or worsens with drug.
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| Antidiarrheals | Short term use only. Decrease GI motility. In general- Do NOT use more than 2 days unless directed by MD**
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| Opiates and Opiate-Related Agents | Decrease intestinal motility decreasing peristalsis. Have the risk of developing an addiction. Tincture of Opium. Ioperamide (immodium)-can be OTC.
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| Diphenoxylate (lomotil) with atropine | Opiod given for traveler's diarrhea. Decrease abdominal cramping, intestinal motility, and hypersecretion. Controlled substance!!!
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| Somatostatin Analog | Dries up GI. For severe diarrhea usually associated with metastatic cancer (some tumors secrete chemicals). May also be result of disruption of epithelial lining. Octreotide (sandostatin)** Can facilitate healing wounds in GI.
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| Adsorbents | Act by coating the wall of GI tract and absorbing the bacteria or toxins causing the diarrhea. Used for traveler's diarrhea. Kaopectate based drug. Parepectolin. Pepto-Bismol.
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| Nonpharmacologic measures for vomiting | Positioning, remove the cause (odor, light, smell), flattened beverage, crackers and dry toast.
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| Nonprescription antiemetics | Antihistamines for motion sickness (take 30 mins prior to travel) ex. Benadryl. Bismuth subsalicylate- pepto bismol. Phosphorated carbohydrate solution: Alka-Seltzer, Bromo-seltzer.
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| Guideline for antiemetics | Should not be used until the underlying cause has been identified
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| Anticholinergic and Antihistamines used for antiemetics | Work primarily in the vomiting center. Useful in treating motion sickness. Ex. meclizine (Antivert). Side effects: drowsiness, dry mouth, blurred vision, tachycardia, and constipation**. Should not be used in clients with glaucoma**
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| Phenothiazine | Dopamine antagonist. Classified as sedative or antipsychotic. Block dopamine 2 receptors in the Chemoreceptor trigger zone***. Used to treat: postoperative nausea, anesthetic related nausea, cancer chemotherapy, radiation therapy.
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| Side effects of Phenothiazine | CNS effects. Extrapyramidal symptoms (EPS)**- stooped posture, rigidity, tremors at rest, shuffling gait, bradykinesia
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| Butyrophenones | Classified as antipsychotics**. Block the dopamine 2 receptors in CTZ. Used to treat nausea r/t: Cancer chemotherapy (long term nausea related to chemo). Radiation therapy: haloperidol (Haldol)***
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| Metoclopramide (Reglan) | Blocks dopamine receptors in CTZ Used as prokinetic- stimulates gastric emptying** Used frequently for pt w/diabetic gastroparesis or tube feedings to decrease risk of aspiration Shouldn't given if client has GI obstruction, hemorrhage, or perforation**
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| Side effects of Metoclopramide (Reglan) | High doses can cause sedation and diarrhea. EPS symptoms**
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| Serotonin receptor antagonist (5-HT3) | Block serotonin receptors in CTZ. Used to treat: postoperative nausea, cancer chemotherapy***. Radiation therapy. ex. Zofran. Oral or IV. Give 30 mins before chemotherapy**. Side effects: headache, constipation, hypotension, dysrhythmias
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| Benzodiazeprines | Lorazepam (Ativan). Used in combination with Serotonin and Glucocorticoid. Effective to treat chemo related nausea. Too much sedation can cause resp depression***
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| Glucocorticoids | Used for nausea associated with chemotherapy along with other antiemetics. Watch for glucose intolerance and increase risk for infection.
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| Cannabinoids | Not legal in OH. The active ingredients in marijuana: marinol. Used for nausea associated with chemotherapy. Only available as tablet, restricted drug on controlled substance list**
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| Emetics | Induce vomiting**. DO NOT induce vomiting if substance is: caustic, petroleum based, unknown.
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| Syrup of Ipecac | OTC drug (formerly recommended for every household to have on hand to give to kids- not NOT recommended b/c of risk of aspiration or further harm from substance ingested). Can be cardio toxic if vomiting does not occur.
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| Administration of Syrup of Ipecac | Only at direction of MD*** Take with glass of water or fluid, not with milk or carbonated beverage. Vomiting occurs 20-30 mins and if not, repeat dose. Gastric lavage may be needed if vomiting does not occur.
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| What is Given to pt if vomiting is contraindicated? | Activated charcoal
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| Ondansetron (Zofran) has been ordered for the client who is taking cancer chemotherapy to control severe nausea and vomiting. What side effects are possible? | Headache, dizziness and fatigue.
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| What are the signs and symptoms of hypokalemia? | Fatigue, muscle weakness, cardiac rhythm disturbance, decreased bowel motility, leg cramps, anorexia, vomiting, nausea
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| How would you schedule the medications for a pt who is to receive an antacid, Carafate, and Dilantin? | Antacids interfere with absorption of other drugs. Carafate can also interfere with absorption or bind up with other drugs. Dilantin has an erratic absorption pattern, should not be given with either of these drugs.
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